New evidence finds standardized cigarette packaging may reduce the number of people who smoke.

According to the World Health Organization (WHO), tobacco use kills more people worldwide than any other preventable cause of death. Global health experts believe the best way to reduce tobacco use is by stopping people starting to use tobacco, and encouraging and helping existing users to stop.

The introduction of standardized (or ‘plain’) packaging was recommended by the WHO Framework Convention on Tobacco Control (WHO FCTC) guidelines. This recommendation was based on evidence around tobacco promotion in general and studies which examined the impact of changes in packaging on knowledge, attitudes, beliefs and behaviour. Standardized tobacco packaging places restrictions on the appearance of tobacco packs so that there is a uniform colour (and in some cases shape), with no logos or branding apart from health warnings and other government-mandated information; the brand name appears in a prescribed uniform font, colour, and size.

A number of countries have implemented, or are in the process of implementing, standardized tobacco packaging. Australia was the first country in the world to implement standardized packaging of tobacco products. The laws, which took full effect there in December 2012, also required enlarged pictorial health warnings.

A team of Cochrane researchers from the UK and Canada have summarized results from studies that examine the impact of standardized packaging on tobacco attitudes and behaviour. They have published their findings in the Cochrane Library.

The author team found 51 studies that looked at standardized packaging. The studies differed in the way they were done and also what they measured. Only one country had implemented standardized packaging at the time of this review, so evidence that tobacco use prevalence may have decreased following standardized packaging comes from one large observational study. A reduction in smoking behaviour is supported by routinely collected data from the Australian government. There are data from a range of other studies to indicate that appeal is lower with standardized packaging and this may help to explain the observed decline in prevalence. Researchers did not find any evidence suggesting that standardized packaging may increase tobacco use. No studies directly measured whether standardized packs influence uptake, cessation, or whether they prevent former smokers from taking up smoking again.

The amount of evidence for standardized packaging has increased markedly since the publication of the WHO guidelines in 2008. However, given its recency, there are no data on long-term impact. The amount of evidence will continue to expand as more countries implement standardized packaging and as studies assessing the longer-term effects of the Australian policy become available.

Cochrane lead author and Deputy Director of the UK Centre for Tobacco and Alcohol Studies, Professor Ann McNeill from King’s College London, said, “Evaluating the impact of standardized packaging on smoking behaviour is difficult to do; but the evidence available to us, whilst limited at this time, indicates that standardized packaging may reduce smoking prevalence. These findings are supported by evidence from a variety of other studies that have shown that standardized packaging reduces the promotional appeal of tobacco packs, in line with the regulatory objectives set. It would appear that the impact of standardized packaging may be affected by the detail of the regulations such as whether they ban descriptors, such as ‘smooth’ or ‘gold’, and control the shape of the tobacco pack.”

Co-author Jamie Hartmann-Boyce, from the Cochrane Tobacco Addiction Group, Oxford, UK, added: “Our evidence suggests that standardized packaging can change attitudes and beliefs about smoking, and the evidence we have so far suggests that standardized packaging may reduce smoking prevalence and increase quit attempts. We didn’t find any studies on whether changing tobacco packaging affects the number of young people starting to smoke, and we look forward to further research on this topic.”

Ann McNeill, Lead AuthorProfessor of Tobacco AddictionUK Centre for Tobacco and Alcohol StudiesNational Addiction CentreInstitute of PsychiatryKing's College LondonLondonUKContact: jack.stonebridge@kcl.ac.uk

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